Compliance Investigator II

Overview:

The Compliance Investigator II has demonstrated competencies in supporting the plan-wide regulatory affairs and compliance program, including activities related to HIPAA, Fraud, Waste, and Abuse (FWA), and compliance issues. As such, conducts investigations to effectively prevent, detect, and mitigate healthcare FWA, privacy and compliance issues. Supports daily operations of the Regulatory Affairs & Compliance unit by ensuring deliverables and all case management performance metrics are met for assigned cases. This position serves as an investigative liaison between the plan and our regulatory agencies and internal departments. 

Responsibilities:

Essential Duties and Responsibilities

 Proficiently performs all duties of the Compliance Investigator, independently.
 Structures and successfully completes investigations independently including writing formal 
investigative reports for privacy, FWA, and compliance matters. In doing so, exercises, 
professional judgement and escalate matters to leadership, as needed.
 Independently conducts investigative interviews, maintaining complete and accurate 
records.
 Prepares formal records and reports in response to enforcement agency requests to support 
investigations, which may include, but not be limited to the Department of Justice and Department 
of Medi-Cal Fraud and Elder Abuse. Demonstrates proficiency and professional acumen when 
interfacing with external stakeholders on behalf of the Plan.
 Works directly with DHCS Privacy Office to report privacy related incidents, provide updates 
upon request, ensure timely filing requirements are met for all reports and follows up on pending 
cases to confirm cases are closed with the DHCS Privacy Office.
 Responsible for identifying trends and linking related cases to assist with trending patterns 
and maintaining accurate data for daily, monthly, quarterly, and annual privacy and FWA analytics, 
including those fraud cases referred for recoveries.
 May provide input regarding controls for monitoring fraud-related issues within the business 
units.
 As directed by manger, performs quality assurance case reviews to ensure they meet DHCS 
requirements, regulatory, and Partnership professional standards.
 Ability to serve as regulatory affairs expert to support complex regulatory inquiries and 
responses to regulatory agencies.
 Encourages continuous awareness and education of unit staff, which may include development and 
maintenance of training materials
 Manages daily case load, prioritizing appropriately, and making recommendations to leadership to 
ensure the timely submission of privacy and FWA cases to DHCS

 Demonstrates proficiency in Manages the intake and ongoing maintenance of referral/inquiry 
platform
 Ability to assess, facilitate, and see to completion, referrals and inquiries, of varying 
complexity and scope, submitted to RAC
 Monitors unit tracking systems to ensure the timeliness of deliverables are met, making 
recommendations for improvements in tracking and/or work flows as necessary
 Competence in assessing and analyzing unit work consistent with established criteria and 
providing recommendations and as directed by manager, provide coaching to unit staff as needed
 Maintains awareness and understanding of regulatory requirements that govern unit 
responsibilities
 Makes strategic recommendation(s) to improve the accuracy, quality, and/or reporting of cases to 
enhance HIPAA, FWA, and compliance issues cases
 Assists Regulatory Affairs Manager with developing, maintaining, and delivering compliance 
training program including but not limited to:
o Updating new hire compliance trainings and annual training materials
o Making recommendations for focused department trainings based on trends and conducting targeted 
department trainings
 Works with departments on resolving complex regulatory required submissions
 Assists Regulatory Affairs Manager with preparing materials and presentations for PTAS and FWA 
Subcommittees

Qualifications:

Education and Experience	Bachelor’s degree in relevant field preferred or equivalent combination of education and experience; minimum of two (2) years’ experience as a Regulatory Affairs Specialist or relevant experience in managed care with knowledge of the Medi-Cal, and NCQA requirements, Medicare and Knox Keene. Experience with the investigation and reporting of HIPAA,FWA, and compliance issues related incidents.
Special Skills, Licenses andCertifications	Highly proficient in applicable business software applications including PC usage, Microsoft Word, PowerPoint, Excel, Project, typing speed of 30 wpm. Valid California driver’s license and proof of current automobile insurance compliant with Partnership policy are required to operate a vehicle and travel for company business
Performance Based Competencies	Excellent oral and written communication skills. Excellent organizational skills with ability to prioritize assignments, maintain effective filing systems, and meet deadlines. Ability to work under minimal supervision and exercise independent judgment. Diplomacy and tact in handling sensitive information regarding personnel affairs as required. Ability to interact with executives and vendors effectively, handling all assignments with efficiency. Must be able to handle multiple tasks and meet deadlines. Excellent judgment.
Work Environment And Physical Demands	Ability to use a computer keyboard and other business machines. More than 50% of work time is spent in front of a computer monitor. When required, ability to move, carry, or lift objects of varying sizes, weighing up to 35 pounds..

 

HIRING RANGE:

 

$96,970.04 - $121,212.56

 

All HealthPlan employees are expected to:

• Provide the highest possible level of service to clients;
• Promote teamwork and cooperative effort among employees;
• Maintain safe practices; and
• Abide by the HealthPlan’s policies and procedures, as they may from time to time be updated.

 

IMPORTANT DISCLAIMER NOTICE

 

The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive of the tasks that an employee may be required to perform.  The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.